Healthcare Provider Details

I. General information

NPI: 1396766812
Provider Name (Legal Business Name): MARSHA R WYKES PT, OCS, CERT. MDT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 ETNA RD
LEBANON NH
03766-1454
US

IV. Provider business mailing address

PO BOX 727
LEBANON NH
03766-0727
US

V. Phone/Fax

Practice location:
  • Phone: 603-643-7788
  • Fax: 603-643-0022
Mailing address:
  • Phone: 603-643-7788
  • Fax: 603-643-0022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number3473
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: